Sample Form: Dr. U's Appointment Inquiry & Consent Form

Dr. U's Appointment Inquiry & Consent Form
Section 1: Contact & Qualification

(Required for Scheduling)
Patient's Full Legal Name*
Patient's WhatsApp Mobile Number*
This is our preferred and fastest channel for sharing appointment details.
Patient's Email Address*
example@example.com
City and State of Residence*
Reason for Consultation*

New Medical ConcernFollow-up/Existing ConditionGeneral Health Check-upSeeking Second Opinion
Preferred Date Range for Appointment*

MonthDayYear
Please provide your availability over the next 7-10 days.
Section 2: The Compliance Check (Mandatory Ethical Consent)

(This proves your diligence in handling patient data and marketing consent ethically, aligning with NMC and general privacy principles.)
Marketing & Communication Consent.
May we occasionally send you useful health tips, clinic updates, and educational material via email/WhatsApp?*
Section 3: Qualification Detail

(Optional but Recommended)
Data Processing & Privacy Consent This links to a legal document that your patient must have (DPDPA/Privacy Compliant).*
How did you hear about Dr. U's Clinic?*
Brief description of your concern (Optional - Do not include sensitive medical history here)
Should be Empty:

Dr. U's Appointment Inquiry & Consent Form